Title: Burnout in Chest Physicians after Health Care Reforms: A Cross-Sectional Study in Turkey

Transcription

1 DOI: /TurkThoracJ Manuscript type: Original Article Title: Burnout in Chest Physicians after Health Care Reforms: A Cross-Sectional Study in Turkey Short Title: The Burnout Syndrome in Chest Physicians in Turkey Authors: Merve Atik 1, Eyüp Sabri Uçan 1, Hülya Ellidokuz 2, Köksal Alptekin 3 Instutions: 1 Department of Chest Diseases, Dokuz Eylül University School of Medicine, İzmir, Turkey 2 Dokuz Eylül University, Institute of Oncology, İzmir, Turkey 3 Department of Psychiatry, Dokuz Eylül University School of Medicine, İzmir, Turkey Address for Correspondence: Merve Atik, Department of Chest Diseases, Dokuz Eylül University School of Medicine, İzmir, Turkey merve_ci@hotmail.com Received: Accepted: Cite this article as: Atik M, Uçan ES, Ellidokuz H, Alptekin K. Burnout in Chest Physicians after Health Care Reforms: A Cross-Sectional Study in Turkey. Turk Thorac J DOI: /TurkThoracJ ABSTRACT OBJECTIVES: The health reform has recently been one of the most important items on the agenda worldwide. The aim of this study is to investigate burnout syndrome in chest physicians and exhibit its connection with reform processes. MATERIALS AND METHODS: In this survey, the Socio-demographic Data Form and Maslach Burnout Inventory were used. Between September and November 2016, chest physicians were reached with permissions by expertise associations via groups. A sample size of 352 physicians was included in the study out of 2,349 chest physicians in Turkey. RESULTS: Among 352 physicians, 238 (67.60%) were women, and the mean age was (±9.97). Higher burnout scores were determined in young physicians (aged 35), residents, those with low income, and those with 55 weekly working hours. The performance-based salary system was regarded as a problem by 84.7%, and 83.5% stated that they had not enough leisure time for

2 themselves and their families. More than a half (55.7%) indicated that they would not choose the same specialty if they ever had a chance to choose again. CONCLUSION: We observed that most of chest physicians in Turkey experience burnout syndrome, which might be influenced by reforms in the health care system. The health system and working conditions should be dealt with immediately by health authorities and reformed in accordance with human dignity and rights to life. KEYWORDS: Burnout syndrome, chest physicians, health care reforms INTRODUCTION Expeditious reforms have come into practice in health politics in countries such as Greece, Portugal, Bulgaria, Romania, Ireland, Croatia, Macedonia, and also Turkey in the last 10 years [1]. This transformation process defined as the health reform pandemic continues to affect the whole world under the leadership of international institutions such as the International Monetary Fund and the World Bank [2,3]. The countries in which health care reforms were shaped by market-oriented regulations are also going through similar processes [1,4,5]. The establishment of market motives in the public health institutions has revealed public health institutions in the health sector markets. As a result of these implementations, expressions such as customer, health service consumer, or health service user have started to be used instead of patient. Because of such performance-based regulations, the number of inpatients has nearly quadrupled, compared to the one prior the health care reform period in Turkey [6]. Emergency service admissions in 2014 exceeded 104 million in Turkey (higher than the population of the country) [7]. By the guidance of market actors, media, and new communication technologies, a lifelike illusion demonstrating diseases that do not exist has been created, and demands of individuals regarding health services have increased. An increase in the number of applications for health care institutions is a reflection of this provoked demand. The performance-based salary system depends on extra payment from a circulating hospital capital account, based on the cumulative amount of individual activities offered to patients. The reflection of this transformation resulted in an increased number (54%) of polyclinics and inpatients (64%) in training-research hospitals connected to the Ministry of Health However, invasive procedures provoked by a performance-based payment system increased disproportionately with the number of patients (for example, bronchoscopy numbers increased to 187%) [8]. It is apparent that this situation leads to erosion in the ethical values of medical practice and compels physicians to alter the content, count, and priority of the service that they offer to their patients. All these procedures have caused physician respectability to decrease in the society and physicians to be displayed as targets for public. Violence and malpractice lawsuits have increased for health professionals. The effect of this degeneration has been revealed as a profound disappointment in health care professionals. Burnout syndrome is one of the most important problems today and an issue that researchers have studied frequently since it affects lives both at the individual and organizational level [9,10]. Various studies have been carried out evaluating burnout in different occupations, as well as in health care

3 professionals up to date. It was stated that burnout is significantly higher in physicians with respect to other occupations [11]. Nevertheless, there is no study examining burnout syndrome in chest diseases in medical literature written in English. In this study we aimed to examine burnout syndrome in chest physicians and establish the risk factors for burnout syndrome and its relationship with health care reforms. MATERIALS AND METHODS In this cross-sectional, descriptive study, all chest physicians (specialists, residents, and academicians working in state hospitals, training and research hospitals, university hospitals, and private health institutions) in Turkey were regarded as the universe of the study. After obtaining an approval from the local ethics committee of Dokuz Eylül University ( / 21-12), written informed consent and survey forms were sent by to the mail groups of chest diseases national associations (Turkish Thoracic Society, Pulmonary Health and Intensive Care Association, and Turkish Respiratory Society) after getting a permission between September and November Every 2 weeks for 3 months, the s were repeated. Some of the chest physicians were reached by telephone and asked to participate in the survey; thus, the physicians with no society memberships were also sampled. In scientific meetings organized by national associations, printed survey forms were distributed to participants, accessible hospitals were visited, and face-to-face interviews were performed. Data Collection To establish burnout in chest physicians and variables leading to burnout in the study, the Sociodemographic Data Form and Maslach Burnout Inventory (MBI) were used together. Socio-demographical Data Form: The form consisted of 29 questions, including those on occupational and socio-demographical characteristics, that were considered to be associated with the burnout levels. Maslach Burnout Inventory (MBI): MBI was developed by Maslach and Jackson. There are 22 items, which are divided into three subscales [12]. Its Turkish adaptation was carried out by Canan Ergin [13]. In the English specific form, it consists of seven answer options including none, a few times a year, once a month, a few times a month, once a week, a few times a week, and every day. Nevertheless, the answer options were narrowed down to five on the grounds that this is more appropriate to Turkish culture in Turkish validation [14]. Emotional Exhaustion (EE): This subscale describes the burnout or overloading emotions by occupation or work. The individuals in a very busy schedule in terms of feelings are overwhelmed by emotional demands of other people. They always tend to run away to minimize the EE they carry. They minimize their relationships adequately enough to deal with their work. These people feel deprived of necessary energy to start a new day. Going to work next day again is a source of anxiety [15]. Depersonalization (D): This subscale describes the individuals behavior toward people they provide service as being deprived of emotions and not considering them as being unique. The person experiencing EE feels powerless in solving problems of other people and uses depersonalization as an

4 escape route. They minimize their relationships sufficiently enough to carry out their work. They treat other people that they render services to as an object; demonstrate insulting and impolite behavior; and ignore their requests and demands [16]. Lack of Personal Accomplishment (LA): Persons going through burnout feel guilty due to the situation that they are in. They deliver a judgment about themselves that they are unsuccessful. Although they try a lot to get positive results, they get stressed and exhibit depression when they notice that they are unsuccessful. They quit trying when they think that trying again will not be beneficial. The decrease in personal success is a frustration perception that they cannot change no matter how hard they try [17]. In the MBI s English form, there are burnout limit values as high, mean, and low, according to the level of it being experienced. In a research carried out with American and Dutch subjects by Schaufeli and Dierendock [18], breakpoints used in the classification of burnout levels are informed to vary from country to country due to social and cultural reasons. The determination of limits specific to every country is stated to be accurate. For a Turkish translation of the MBI survey, there are no limit values which validity has been studied in their sub-dimensions [13,14,17]. Therefore, the values were compared between the groups by taking median values in this study. Since there is no cut-off value for us to comment whether the burnout exists, a categorical classification was not performed. Statistical Analysis A statistical analysis was performed using the IBM Statistical Package for the Social Sciences for Windows 22.0 software (IBM SPSS Statistics Corp.; Armonk, NY, USA). Its suitability for normal distribution was checked by the Kolmogorov-Smirnov and Shapiro-Wilk tests. It was checked whether it is appropriate for normal distribution or not; thus, nonparametric tests were used in statistical methods. In the comparison of average values of numeric variables of dual groups, the Mann- Whitney U and Pearson s chi-squared test were used, and Bonferonni corrected Kruskal-Wallis test was utilized in the comparison of numeric variables of more than two groups. The covariance analysis was used to measure the effects on dependent variables of more than one independent variable. The significance level was accepted as p<0.05. RESULTS A total of 352 chest physicians were involved in the study, including 105 (29.8%) residents, 148 (42%) specialists, and 99 (28.1%) academicians. Of the participants, 238 (67.6%) were women. The mean age of chest physicians distributed in the age group between 24 and 63 was (±9.97). Most of the chest physicians (64.5%) thought their income was insufficient. The ratio of being appreciated by managers was only 15.6% when physicians completed a task successfully. Eighty-three percent (n=294) of the physicians stated that they had insufficient leisure time for themselves and their families. The demographical features of chest physicians involved in the study are presented in Table 1. When demographic data and their relationship with the burnout sub-dimensions were analyzed, the burnout levels in the EE, D, and LA sub-dimensions were found to be significantly higher in physicians aged 35 (p<0.001). In female physicians, a significant difference was determined in the sub-

5 dimension of EE (p<0.05). According to the academic degree, the burnout levels in residents and specialists were identified significantly higher compared to academicians in all three sub-dimensions (p<0.001). With regard to the employment institution, the lowest EE, D, and LA scores were found in physicians working at private health institutions (p<0.05). The EE, D, and LA were found to be higher in the first 5 years of employment (p<0.05) (Table 2). Higher scores were found in the EE, D, and LA sub-dimensions of physicians working 55 hours/week (p<0.001). A significant relationship was found between the number of night shifts and the burnout level (p<0.001) (Figure 1). Among the chest physicians involved in our study, 55.7% answered the question, If you had a chance for re-preference, would you choose the same specialty? as no. When physicians were asked what was the major problem related to the occupation choice, or if they might experience it in the future, 298 (84.7%) replied that it was the performance system ; 298 (84.7%) the relations with managers ; 287 (81.5%) insufficient spare time for academic study/education ; and 282 (80.1%) the insufficient salary system (Table 3). DISCUSSION In this study, we observed that the majority of chest physicians perceive changing working conditions, patient-physician relations, and performance-based salary system as a problem. Many physicians think that they are not appreciated by managers. This situation has led to further burnout especially in young physicians. The average burnout scores of chest physicians involved in our study were compared with the results from another study [19] examining physicians in Turkey in The authors found that every three burnout sub-dimensions were high (p<0.001). This difference is thought to be caused by the effects of health reforms performed in recent years in Turkey or that the burnout level in chest physicians is higher than the average burnout level of other specialties. As a result of increased hospital admissions with provoked demand after the health reforms in Turkey, the workload on physicians increased, and deformation occurred in the patient-physician relationship. This situation caused occupational dissatisfaction in 69% of chest physicians involved in our study. Storlie defined burnout as collapse of the human spirit. According to Storlie, this sneaky process was explained as the perception, that no matter what you do or how hard you try, you cannot make a difference [20]. In one of the studies, the burnout levels in physicians were compared to those in other jobs; it was reported that the burnout prevalence of physicians in America reached the alarming levels; the working hours of physicians were longer than in other white-collar professions [11]. In the same study, the physicians stated that 36% of them had no adequate time for their private life [11]. In our study, however, 83% of chest physicians mentioned that they had not enough time for leisure activities. This result shows the necessity of rearrangement of working hours and shift physicians concepts.

6 In the present study, higher burnout levels were found in the EE, D, and LA dimensions of young population. According to Cherniss, this situation is associated with insufficient levels of coping skills, instinct, and interior skills of the young [21]. In the first 5 years of the occupation, the finding that the burnout level is high in the newest ones (p<0.001) may also be related to examining more patients compared to senior physicians, doing more routine work, having more supervision pressure, and having no satisfactory status features. In our study, the EE, D and LA sub-dimension scores of residents and specialists were found to be higher than those of academicians. This situation remained significant when covariance analysis and age variables were removed (p<0.05). It is reported that more burnout syndrome has gone through in the lower steps of various occupation groups in literature [22,23]. The lowest score of the EE, D and LA sub-dimensions was observed in the workers of private health institutions; the highest score, however, was in those working at state hospitals. Having high salary and prestige at private health institutions were thought to be associated with lower burnout levels. Having more research and personal development opportunities at universities and training and research hospitals provide benefit in being protected from burnout by increasing occupational satisfaction. Working in an academic institution is known to be a factor preventing from burnout [24]. In a study carried out to search the relationship between the prevalence of insomnia symptoms and sleeping quality of the physicians with high and low burnout scores in Spain, the burnout was established to be related to all insomnia symptoms highly as a result of multivariate logistic regression [25]. When physicians with no shift, three or less than three shifts, and more than three shifts were evaluated, a significant difference was determined in the EE, D, and LA subdimensions of all three groups (p<0.001) (Figure 1). The situations when financial or emotional expectations of the individuals are not met satisfactorily are known to form a risk for burnout. Only 8.8% of the physicians involved in our study thought that their income was adequate. In those who find their salaries are sufficient, the burnout in the EE and D dimensions was found to be significantly low (p<0.001). Only 15.6% of the physicians involved in our study thought that their success was appreciated by their managers. Burnout scores in EE sub-dimensions of physicians who thought to be appreciated by their managers were determined to be lower (p<0.001). In a study carried out by Visser et al. [26], mismanagement and not feeling any support were indicated as vital factors decreasing the work satisfaction. In a study performed by McManus et al. [27], it was emphasized that giving physicians a chance in the mechanisms of decision making; showing the necessity of their control and autonomies; and making them understand that they are valuable while running through their needs were important. Our study demonstrated that 84.7% of the physicians evaluate a performance-based system -a part of the changing health system-as a problem. Physicians who were not satisfied with the performance-based system had significantly higher EE and D scores. It made us think that if physicians are left in a dead-end between ethical values and income: It either makes them insensitive by putting their income first or makes them go through EE by choosing ethical values.

7 In this study, the communication issues between the patient and patient s relatives are perceived as a problematic by 63.9% of chest physicians. Their contribution to burnout was found to be significant in all sub-dimensions (p<0.001). Ever-increasing communication issues and violence in recent years have become an important problem for health professionals, and it causes work stress to raise the work load independently [28]. There have been five murders of chest physicians and chest surgeons in the last 5 years, as reported by Turkish media. Between January 2015 and April 2017, 25,443 violence cases were reported to the Health Ministry. A total of 6,893 of these cases were physical violence, and verbal abuse cases were 18,550. These data were sourced from the Turkish Medical Association official website ( A significant difference was determined in the EE and D sub-dimensions of burnout in physicians (81.5%) reporting that they did not have spare time for academic study/education (p<0.05). In a previous study including physicians, when professional personal competency was developed, it was reported that stress related to occupation decreased to a large extent, and an important motivation source concerning work satisfaction depending on this situation also increased. In the same study, it was also emphasized that personal competency is one of the most important anti-stress sources [29]. In our study, 61.4% of chest physicians answered the statement I do not mind what happened to people that I met due to my job with never. Despite all negativities and burnout, the majority of physicians will continue to use their time for their patients as they promised rather than for themselves, families, and children. Nonetheless, on the other side of the medallion, the fact that physicians do not care about their patients now and again is of importance. In a previous study that examined the burnout in surgeons, it was shown that major medical errors made in the past 3 months increased to 11% with one score up (scale interval 0-33) in depersonalization dimension; it was also emphasized that a serious potential formed in view of the urge of the physician as first do no harm [30]. Hospitals are places where the well-being of staff is symbiotically related to patients well-being. Depersonalization of physicians, however, will be a disaster for the whole society. This study is, to the best of our knowledge, is the first study in the English language in medical literature where burnout syndrome was analyzed in chest physicians following health reforms. There are some limitations to our study. The first one is that since there are no limit values in terms of validity and reliability of MBI in its Turkish translation, the burnout levels were grouped as low, median, and high [14]. Not being able to categorize is the biggest limitation to the study. The second one is that the majority of the physicians involved in the study comprised those who replied to survey forms sent collectively. It is possible that those replied with selective perception were really replied by individuals suffering from a burnout. The third limitation is that the study was only performed in chest physicians in Turkey. It solely provides information about local variables. Therefore, similar studies are required in countries where health reforms have gone through. In a globalized world, as a result of health systems formed by market-oriented regulations, a burnout at the emotional level, depersonalization, and decrease in personal success are particularly more commonly seen in young chest physicians. More than a half of chest physicians implied that they regret their preferences, and this ratio reached 58.2% in young physicians. It is clear that our young colleagues feel the transformation in health services deeply and severely, and this situation threatens the future of the chest diseases field, unless the new regulations in the near future not only consider the needs of patients, but also the needs of medical staff.

8 Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Dokuz Eylul University ( / 21-12). Informed Consent: Written informed consent was obtained from all participants of this study. Peer-review: Externally peer-reviewed. Author Contributions: Concept -M.A.,E.S.U.; Design - M.A.,E.S.U; Supervision - E.S.U.; Resources - M.A.; Materials - M.A., K.A.; Data Collection and/or Processing - M.A.,E.S.U.; Analysis and/or Interpretation - H.E., M.A.,E.S.U., K.A.; Literature Search - M.A.,E.S.U., K.A..; Writing Manuscript - M.A.,E.S.U.; Critical Review - H.E., M.A.,E.S.U., K.A.; Other M.A. Conflict of Interest: The authors have no conflicts of interest to declare. Financial Disclosure: The authors declared that this study has received no financial support. REFERENCES 1. Montgomery A, Todorova I, Baban A, et al. Improving quality and safety in the hospital: The link between organizational culture, burnout, and quality of care. Br J Health Psychol 2013;18: Yavuz CI, Hamzaoğlu O. Sağlık bakanlıklarının Türkiye ve Dünyada yeniden yapılandırılması. Toplum ve Hekim 2013;28: Hamzaoğlu O. Dünyada sağlık reformu Türkiye de sağlıkta dönüşüm: gerçekler ve belgeleri. Toplum ve Hekim 2013;28: Spânu F, Băban A, Bria M, Dumitrascu DL. What happens to health professionals when the ill patient is the health care system? Understanding the experience of practising medicine in the Romanian socio cultural context. Br J Health Psychol 2013;18: Todorova IL, Alexandrova-Karamanova A, Panayotova Y, et al. Organizational hierarchies in Bulgarian hospitals and perceptions of justice. Br J Health Psychol 2014;19: Köse MR, Başara B, Güler C. Sağlık istatistikleri yıllığı Ankara, TC Sağlık Bakanlığı Sağlık Araştırmaları Genel Müdürlüğü 2014; Çukurova Z, Akın M, Özgül E. Kamu Hastaneleri istatistik yıllığı Ankara, Türkiye Kamu Hastaneleri Kurumu, Sağlık Bakanlığı Yayın No: 1000, 2015; Altın S. What changed in the Chest Diseases Education Hospitals in the last 5 years? Turkish Thoracic Society 14th Annual Congress Abstract Book: ss-166. Antalya, Turkey. April Kroll H, Macaulay T, Jesse M. A Preliminary Survey Examining Predictors of Burnout in Pain Medicine Physicians in the United States. Pain Physician 2016;19:E Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52: Shanafelt TD, Boone S, Tan L. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172: Maslach C, Jackson SE. Maslach burnout inventory. Research edition. Manual, Consulting Psychologists Press, 1981.

9 13. Ergin C. Doktor ve hemşirelerde tükenmişlik ve Maslach tükenmişlik ölçeğinin uyarlanması. VII. Ulusal psikoloji kongresi bilimsel çalışmaları 1992;22: Ergin C. Maslach tükenmişlik ölçeğinin Türkiye sağlık personeli normları. 3P Dergisi 1996;4: Martin Rod A. The psychology of humor. An intergrative approach. Burlington, Elsevier Academic Publication, Maslach C, Jackson SE. A social psychological analysis. Social Psychology of Health and Illness 2013; Çam O. The burnout in nursing academicians in Turkey. Int J Nurs Stud 2001;38: Schaufeli WB, Van Dierendonck D. A cautionary note about the cross-national and clinical validity of cut-off points for the Maslach Burnout Inventory. Psychol Rep 1995;76: Aslan D. Burnout syndrome and influencing factors in some of the physicians registered in Chambers of Physicians in Turkey. Ankara, Türk Tabipleri Birliği Yayınları, Storlie FJ. Burnout: the elaboration of a concept. Am J Nurs 1979;79: Cherniss C. Professional burnout in human service organizations. New York, Praeger Publishers, Polatcı S. Tükenmişlik sendromu ve tükenmişlik sendromuna etki eden faktörler (Gaziosmanpaşa Üniversitesi akademik personeli üzerinde bir analiz). Tokat, Gaziosmanpaşa Üniversitesi Sosyal Bilimler Enstitüsü, Yüksek lisans tezi, Ergin C. Akademisyenlerde tükenmişlik ve çeşitli stres kaynaklarının incelenmesi. Edebiyat Fakültesi Dergisi 1995; Liakopoulou M. Burnout, staff support, and coping in pediatric oncology. Support Care Cancer 2008;16: Vela-Bueno A, Moreno -Jiménez B, Rodríguez-Muñoz A, et al. Insomnia and sleep quality among primary care physicians with low and high burnout levels. J Psychosom Res 2008;64: Visser MR, Smets EM, Oort FJ, et al. Stress, satisfaction and burnout among dutch medical specialists. CMAJ 2003;168: McManus IC, Winder B, Gordon D. The causal links between stress and burnout in a longitudinal study of UK doctors. Lancet 2002;359: Erdur B. Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey. Ulus Travma Acil Cerrahi Derg 2015;21: Kushnir T, Cohen AH, Kitai E. Continuing medical education and primary physicians job stress, burnout and dissatisfaction. Med Educ 2000;34: Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc 2016;91:

10 Table 1. Characteristics of chest physicians Characteristics n=352 (100%) Sex Female Male % % Age 35 > % % Marital status Single % Married % Divorced % The number of dependent children Employment institution Married live apart 1.4% None % % % % State hospital % T&R hospital % University % PHI % Academic degree Assistant % Specialist % Academician % Employment duration 5 years % 6-10 years % >10 years % Salary % % % Sufficient income belief Being appreciated by managers Yes % No % Partially % Yes % No % Sometimes % 5

11 Efficient leisure Yes % time for himself/herself or his/her family No % PHI: private health institution; T&R hospital: training and research hospital Table 2. Characteristics, occupational features of chest physicians, and their relationship with burnout Chest Physicians Total n=352 Burnout EE Median (min-max) Burnout D Median (min-max) Burnout LA Median (min-max) 20 (0-36) 7 (0-20) 11 (0-32) Sex Female 20 (0-36) 7 (0-20) 12 (0-27) Male 18 (0-36) 7 (0-20) 10.5 (0-32) p Age 35 21(3-36) 9(2-20) 13(0-32) >35 19(0-36) 6(0-18) 10(0-20) p <0.001 <0.001 <0.001 Marital Status Single 20 (0-36) 9 (0-20) 14 (0-32) Married 19 (0-36) 7 (0-20) 11 (0-27)

12 Divorced 18 (4-32) 7 (0-11) 10 (0-19) Married live apart 26 (7-34) 12 (2-16) 6 (3-22) p The number of children None 20 (0-36) 9 (0-20) 13 (0-32) 1 20(0-36) 6 (0-18) 10 (0-25) 2 19 (4-36) 6 (0-16) 10 (0-27) 3 16(11-35) 8 (1-14) 5 (1-18) p <0.001 <0.001 Employment institution State hospital 23 ( 0-36) 8 (0-16) 13 (0-25) T&R hospital 20(5-36) 7(0-20) 12(1-32) University 19( 0-36) 7(0-20) 11 (0-27) PHI 14(6-28) 4 (0-15) 6 (0-25) p <0.001 Academic degree* Assistant 22 (3-36) 10 (2-20) 14 (0-32) Specialist 20 (0-36) 7 (0-18) 11 (0-27) Academician 15 (0-32) 4 (0-14) 9 (0-26) p <0.001 <0.001 <0.001 Employment duration 5 years 22 (7-36) 10 (2-20) 14 (0-32) >5 years 19(0-36) 6 (0-18) 11 (0-27) p <0.001 < Salary (0-36) 8 (0-20) 12 (0-32) (0-30) 4 (0-18) 10 (0-24) (5-20) 3( 0-13) 5 (4-11) p <0.001 < Sufficient income belief Yes 17 (0-33) 5 (0-18) 10 (0-24) No 17 (7-36) 6 (0-15) 11 (1-27) Partially 21 (0-36) 8( 0-20) 12 (0-32) p < Being appreciated by managers Efficient leisure time for himself or his family Yes 15 (0-33) 7 (0-16) 10 (0-24) No 21 (0-36) 8 (0-20) 11 (0-32) Sometimes 19 (3-36) 7 (0-20) 12 (0-27) p < Yes 14(0-32) 5(0-15) 8(0-25) No 21(0-36) 8 (0-20) 12 (0-32) p *When the covariance analysis and age variable were taken away, a significant difference was found in all three sub-dimensions (EE, p=0.007; D, p=0.002; LA, p=0.004) E: emotional exhaustion; D: depersonalization; LA: lack of personal accomplishment; PHI: private health institution; T&R hospital: training and research hospital

13 Table 3. The major problem that physicians think they experience or may experience in the future n (%) Burnout EE Median (min-max) Burnout D Median (min-max) Burnout LA Median (min-max) Sociopolitical situation in the country 305 (86.6%) Performance system 298 (84.7%) < Poor relations with managers 298 (84.7%) <0.001 < Not enough spare time for academic study/education 287 (81.5%) < Insufficient salary system 282 (80.1%) < Not enough spare time for personal interests 279 (79.3%) < Patients with high mortality/chronic diseases 273 (77.6%) < Inadequate physical conditions 257 (73.0%) <0.001 < Inconvenient work/on duty/shift conditions 253 (71.9%) <0.001 <0.001 <0.001 Occupational dissatisfaction 245 (69.6%) <0.001 < Communication problems with patients and patient relatives 225 (63.9%) <0.001 < Not able to choose the place where they are going to live 213 (60.5%) <0.001 < Disruption of family integrity 158 (44.9%) < Poor relations with colleagues 120 (34.1%) E: emotional exhaustion; D: depersonalization; LA: lack of personal accomplishment

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16 Figure 1. The association between sub-dimensions of burnout and characteristics of chest physicians